Provider Demographics
NPI:1922037134
Name:NORTHEAST GUIDANCE CENTER
Entity Type:Organization
Organization Name:NORTHEAST GUIDANCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICE
Authorized Official - Prefix:MS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:NEDERLANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-824-5542
Mailing Address - Street 1:2900 CONNER AVE
Mailing Address - Street 2:BLDG A
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2061
Mailing Address - Country:US
Mailing Address - Phone:313-308-1400
Mailing Address - Fax:313-308-1600
Practice Address - Street 1:12800 E WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2601
Practice Address - Country:US
Practice Address - Phone:313-824-8000
Practice Address - Fax:313-824-5589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104682983Medicaid
MI21-3119549Medicaid
MI750910874OtherBLUE CROSS BLUE SHEILD MI
MI0H26233Medicare PIN